AD-A274 200

AD

CONTRACT NO: DAMD17-85-C-5133

TITLE: PHASE I CLINICAL PHARMACOLOGY STUDIES

PRINCIPAL INVESTIGATOR: Paul S. Lietman, M.D., Ph.D.Brent G. Petty, M.D.

CONTRACTING ORGANIZATION: The Johns Hopkins UniversitySchool of MedicineDivision of Clinical Pharmacology600 North Wolfe StreetBaltimore, Maryland 21287-5554

REPORT DATE: September 28, 1993 D TICEIECTE

0EC2 7.1993TYPE OF REPORT: Annual Report S,'APREPARED FOR: U.S. Army Medical Research and

Development Command, Fort DetrickFrederick, Maryland 21702-5012

DISTRIBUTION STATEMENT: Approved for public release;distribution unlimited

The views, opinions and/or findings contained in this report arethose of the author(s) and should not be construed as an officialDepartment of the Army position, policy or decision unless sodesignated by other documentation.

9 3 -31229

93 12 23 074

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1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE I3. REPORT TYPE AND DATES COVERED

12R Sentepmer I99• La Retort (9/1l90 - 8/31/91•4, TITLE AND SUBTITLE S. FUNDING NUMBERS

Phase I Clinical Pharmacology Studies Contract No.DAMD17-85-C-5133

6. AUTHOR(S)

Paul S. Lietman, M.D., Ph.D.Brent G. Petty, M.D.

7, PERFORMING ORGANIZATION NAME(S) AND ADORESS(ES) B. PERFORMING ORGANIZATION

The Johns Hopkins University REPORT NUMBER

School of MedicineDivision of Clinical Pharmacology600 North Wolfe StreetBaltimore. Maryland 21287-5554

9. SPONSORING / MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING / MONITORING

U.S. Army Medical Research & Development Coiman AGENCY REPORT NUMBER

Fort DetrickFrederick, Maryland 21702-5012

11. SUPPLEMENTARY NOTES

lia. DISTRIBUTION/ AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE

Approved for public release; distribution unlimited

13. ABSTRACT (MaXimum 200 words)

Description of progress under Task Order #7, #8, #9, #10, #11,#12, #13, and #14.

14. SUBJECT TERMS IS. NUMBER OF PAGES

Pharmacolinetics, Pharmacodynamics, Drugs, Infectious 16,_PRICECODE.Diseases, Pyridostigmine, Acetylcholinesterase, 16. PRICE CODEPharmacoloqy Bioavailabilit, RAD I, V

17. SECURITY CLASSIFICATION 18. SECURITY CLASSIFICATION 19. SECURITY CLASSIFICATION 20. LIMITATION OF ABSTRACTOF REPORT OF THIS PAGE OF ABSTRACT

Unclassified Unclassified Unclassified UnlimitedNSN 7540-01-280-5500 Standard Form 298 (Rev 2-89)

Prscribe1d by ANS0I Std 1919'295- 302

summary

This annual report contains a listing of the task orders and workperformed on each during the period of September 1, 1990 throughAugust 31, 1991 for Contract No. DAMD17-85-C-5133. Appendix Alists the issue dates for the final reports for Task Orders # 7, 8,9, 10, 11, 12, 13, and 14. Appendices B, C, D, F, G, H, I, and Jprovide summaries of the results of the Task Orders. Appendix E isa copy of the abstract of the results of Task order #10.

fl i': "_ 1 . . . .

Foreword

Citations of commercial organizations andtrade names in this report do not constitutean official Department of the Army endorsementor approval of the products or services ofthese organizations.

For the protection of human subjects theinvestigators have adhered to policies ofapplicable Federal Law 45CFR46.

List of ARvendices

Appendix A Task Order Final Reports: Dates of Issue

Appendix B Summary of Task Order #7

Appendix C Summary of Task Order #8

Appendix D Summary of Task Order #9

Appendix E Abstract of Results of Task Order #10

Appendix F Summary of Task Order #10

Appendix G Summary of Task Order #11

Appendix H Summary of Task Order #12

Appendix I Summary of Task Order #13

Appendix J Summary of Task Order #14

Body of Report

During this period of the contract, our group worked on thefollowing Task Orders:

1. Task Order #7

Title: "Pharmacokinetics and Pharmacodynamics of Sustained,Low-dose, Intravenous Infusions of Pyridostigmine"

The clinical portion was conducted between July 27, 1987and October 16, 1987 and evaluation of the data continued.The date the final report was issued is listed in Appendix A.Appendix B is the summary of the results.

2. Task Order #8

Title: "Safety, Tolerance, Pharmacokinetics andPharmacodynamics of Single Oral Doses of Sustained-releasePyridostigmine in Healthy Men"

The clinical portion was initiated on January 11, 1988and was completed on April 23, 1988. The preparation of drafttask reports was under way. Several drafts had been submittedby our group to the Contracting Officer Representative, Col.Brian Schuster, for his review and review by his associates.The suggestions for revisions based on those reviews wereincorporated into additional draft task reports, and by theend of this reporting period the process of finalizing thetask report was almost completed. The date the final reportwas issued is listed in Appendix A. Appendix C summarizes theresults.

3. Task Order #9

Title: "Safety, Tolerance, Pharmacokinetics andPharmacodynamics of Single Oral Doses of Sustained-releasePyridostigmine (Duphar) in Healthy Men"

The clinical portion was conducted between March 28, 1988and April 30, 1988. Draft task reports had been prepared andrevised. Several drafts had been submitted for review by Col.Schuster and his associates. The suggested revisions based onthose reviews were incorporated into additional drafts, and bythe end of this reporting period the process of finalizing thetask report was almost completed. The date the final reportwas issued is listed in Appendix A. The results of the studyare summarized in Appendix D.

4. Task Order #10

Title: "Multiple-dose Pharmacokinetics, Safety and Toleranceof WR 6026 Hydrochloride in Healthy Subjects"

The clinical portion of this project was initiated onAugust 16, 1988 and had been completed on December 16, 1988.The data were collected and analyzed for drafting the taskreport. The draft task report was submitted to Col. Schusterfor review by him and by his associates. Suggestions forimprovement were made, and substantial dialogue followed asadditional draft task reports were exchanged and reviewed. Inaddition, in collaboration with Col. Schuster, it was decidedto have all of the electrocardiograms recorded in this studyreviewed independently by a cardiologist. The process ofreview and revision of the draft task reports was completedshortly before the end of this reporting period, with theformal Task Report being issued on August 21, 1991. Anabstract describing the results of the study was submitted tothe 31st Interscience Conference on Antimicrobial Agents andChemotherapy, and was accepted for presentation at thismeeting which took place in Chicago, Illinois over the periodSeptember 29-October 2, 1991 (Appendix E). The results aresummarized in Appendix F.

5. Task Order #Il

Title: "Safety, Tolerance, Pharmacokinetics andPharmacodynamics of Single Oral Doses of PyridostigmineAdministered by an Osmotic-delivery Module (Osmet R) Comparedto Pyridostigmine Syrup in Healthy Men"

The clinical portion of this project, which began onJanuary 8, 1989, had been completed on February 3, 1989. Thedata had been collected and analysis initiated for preparingthe task report. During this reporting period, several draftsof the task report were submitted for review by Col. Schusterand his associates. The suggested revisions based on thosereviews were incorporated into additional drafts, and by theend of this reporting period the process of finalizing thetask report was almost completed. The date the final reportwas issued is listed in Appendix A. Appendix G provides asummary of the results.

6. Task Order #12

Title: "Safety, Tolerance, Pharmacokinetics andPharmacodynamics of Single Oral Doses of a CommercialFnrmulation of Sustained-release Pyridostigmine in HealthyMen"

The clinical portion of this project was conductedbetween December 12 and December 23, 1988. The data had beencollected and analysis initiated for preparing the taskreport. During this reporting period, several drafts of thetask report were submitted for review by Col. Schuster and hisassociates. The suggested revisions based on those reviewswere incorporated into additional drafts, and by the end ofthis reporting period the process of finalizing the taskreport was almost completed. The date the final report wasissued is listed in Appendix A. The results of this TaskOrder are summarized in Appendix H.

7. Task Order 113

Title: "A Protocol to Assess the Irritancy, ContactSensitization and Contact Photoallergic Potential ofNiclosamide - A Topical Anti-schistosomal Agent"

The clinical portion of this study was initiated onDecember 21, 1989 and was completed on July 20, 1990.Throughout the conduct of this study, close collaborationcontinued between our group and Army personnel at Walter Reedand at Ft. Detrick. Necessary amendments to the protocol weremade to facilitate the completion of the project in a properfashion. The data were analyzed and drafts of the task reportwere prepared and submitted for review by Col. Schuster andother Army personnel. Using the suggestions coming from thesereviews, and after discussion within our group, the draftswere revised and reviewed again. The final report was issuedon April 18, 1991. Appendix I summarizes the results.

8. Task Order #14

Title: "Safety, Tolerance, Pharmacokinetics andPharmacodynamics of Intravenous Pyridostigmine and Oral Dosesof Standard and Sustained-release Pyridostigmine in HealthyMen and the Influence of Food on Oral PyridostigminePharmacokinetics"

The clinical portion of this study was initiated on March11, 1990 and had been completed on May 26, 1990. Thecollection and analysis of the data continued in preparationfor drafting the task report. The date the final report wasissued is listed in Appendix A. Appendix J provides a summaryof the results.

Appendix A

Task Order Final Reports: Dates of Issue

Task Order #7 August 7, 1993

Task Order IS September 28, 1991

Task Order #9 September 29, 1991

Task Order #10 August 21, 1991

Task Order #Il November 11, 1991

Task Order #12 October 22, 1991

Task Order #13 April 18, 1991

Task Order #14 February 16, 1993

APPENDIX B

SUHMARY T.O. #7

Pyridostigmine bromide may be a useful adjunct to atropine sulfate to

prevent death from organophosphace exposure if given in advance of the

exposure and if given in a dose that is adequate to inhibit red blood cell

acetylcholinesterase by 20-40%. The inter-individual variability to a known,

constant exposure to pyridostigmine is poorly characterized.

This study was designed (1) to assess the relationship between plasma

concentrations of pyridostigmine and erythrocyte acetylcholinesterase

inhibition, (2) to determine whether erythrocyte acetylcholinesterase and the

contractile response of the iris to light are inhibited in a parallel fashion

by pyridostigmine, and (3) to assess the inter-individual variations in the

concentration-effect relationships described in L and 2.

The clinical portion of the study was conducted between 27 July and 16

October 1987, and shoved that the constant intravenous infusion of .low doses

of pyridostigmine was safe and well tolerated. Intravenous pyridostigmine

gave relatively steady plasma concentrations of pyridostigmine and erythrocyte

acetylcholinesterase inhibition during the latter portion of the infusions.

Mean peak erythrocyte acetylcholinesterase inhibitions were 29% and 36% for

infusions of 12.5 mcg/minute and 18.75 mcg/minute, respectively. The mean

rate constant of elimination was 1.365 hr'1, corresponding to an elimination

half-life of 30 minutes. The mean plasma clearance was 44.62 L/hr, or 744

ml/minute. The mean concentration at which 50% of the erythrocyte

acetylcholLnescerase activity was inhibited (IC . 0) was 31.8 nrg/ml. The

(APPENDIX i3 p. ') T . . ;7

influence of these infusions on the contractile response of r'.e Iris was

difficult to measure and could not be reliably standardized due to technical

limitations. Because these problems introduced zeriou.s uncertainty into

measuring pupillary response to the Infusions, no correlation with plasma

pyridostigmine levels or acetylcholinesterase inhibition could be assessed.

APPENDIX C

SUMMARY T.O. #8

Pyridoscigmine bromide may be a useful agent to prevent dea•h from

organophosphace exposure if given in advance of the exposure and if given in a

dose chat Is adequate to inhibit red blood cell acetylcholinesterase by 20-

40%. A previous study conducted at our Institution determined that 16 mg of

pyridostigmine bromide administered as syrup inhibited red blood cell

aceryicholinesterase by 20-40% within one hour after dosing, but the

inhibition fell below 20% by about five hours after dosing. In an effort to

find a formulation that would provide adequate acecylcholinescerase inhibition

for a longer period, sustained-release formulations are being developed.

This study was designed (1) to compare the pyridostigmine bromide

pharmacokinecics in healthy men after single doses of 22 ag of pyridostigmine

bromide as syrup and after 22 mg of pyridosntigmine bromide in cwo different

sustained-release formulations, (2) to characterize the time course of red

blood cell acetylcholinesterase inhibition following the administration of the

two dosage forms of oral sustained-release pyridosrigmine bromide and compare

these to the inhibition occurring after oral pyridoscigmine bromide syrup, (3)

to assess the pharmacodynamic relationship between pyridostigmine plasma

levels and erythrocyte acetylcholinesterase inhibition, and (4) to assess the

safety and tolerance of these two sustained-release formulations compared to

pyridostigmine bromide syrup.

The clinical portion of the sr idy was conducted between 11 January and

23 April 1988. The two sustained-release formulations were less well

absorbed than the pyridostigmine syrup, measured either by direct plasma level

assay or by effect on red blood cell acecylcholinesterase activity. The

(APPENDIX C p.2)T.O. #/8

relative bioavailabiltY of the -slow-release" tablet compared tu syrup was

51% by direct plasma level measurement and 60% by effect on

acetylcholinesterase activity. The relative bioavailability of the "fast-

release" tablet compared to syrup was greater than thac for the slow-release

tablet, 62% by direcu plasma level measurement and 83% by effect on

acecylcholilnesterase activity. Doubling the dose of fast-release tablets

still did nrot achieve the plasma levels or acetylCholinesterase inhibition of

the syrup at half the dose. The subjects tolerated the adminisCration of

pyridost igmine well.

APPENDIX D

SUMMARY T.O. #9

Pyridostigmine bromide may be a useful agent to prevent death from

organophosphate exposure if given in advance of the exposure and if given in a

dose chat is adequate to inhibit red blood cell ace-ylcho linesterase by 20-

40%. A previous study conducted at our institution determined that 16 mg of

pyridostigmine bromide administered as syrup inhibited red blood cell

acetylcholinesterase by 20-40% within one hour after dosing, but the

inhibition fell below 20% by about five hours after dosing. Another study

showed that 22 mg of syrup gave an average peak inhibition of 35% and provided

at lease 20% inhibition fGr slightly over 4 hours. In an effort to find a

formulation that would provide adequate acetylcholinesterase inhibition for a

longer period and be more convenient for dosing than syrup, sustained-release

formulations are baing developed.

This study was designed (1) to compare the pyridostigmine bromide

pharmacokinectis in healthy men after single doses of 45 ag of pyridostigmine

bromide as syrup and after 45 ag of pyridostigmine bromide in two different

sustained- release formulations, (2) to characterize the time course of red

blood cell acecylcholineoterase inhibition following the administration of the

two dosage forms of oral sustained-release pyridoscigmine bromide and compare

these to the inhibition occurring after oral pyridoscigmine bromide syrup, and

(3) to assess the safety and tolerance of these two susr~tined-release

formulations compared to pyridostigoine bromide syrup.

(APPFNDIX D p. 2 )

T.O. #/9

The clinical portion of the study was conducted between 28 Harch and 30

April 1988. The two sustained-release formulations were less well absorbed

than the pyridoscigmine syrup, measured either by direct plasma level assay or

by effect on red blood cell acetylchollnesterase activity. The relative

bioavailability of the "slow-release" capsule compared to syrup was 41% by

direct plasma measurement and 47% by effect on acecylcholinesterase activity.

The relative bioavailability of the "fast-release" capsule compared to syrup

was greater than that for the "slow-release" capsule. 700 by direct plasma

level measurement and 77% by affect on acecylcholinesterase activity. The

subjects tolerated the administration of pyridostigmine well.

APPENDIX E

ABSTRACTS OF THE 1991 ICAAC 227

77uit-.;ite.2oas PhataeCokinaCICS. Safety. anld 770 FoundAntrasvwI6gA Rasvormas inSyrniplaneauk.Tolerance of I,'R 6026. a Promising Drug for Aayyiemn m andUnmdaChidren. mhL 1via.gi

E~aa±LPno',.uien La. KC PZETTY Horsv 00 MaT5cas. UK Earn. IA ftwina. univterstyYOR2sNIWE. IS ýTr . fl.LT'YL2±3.IL. Pl.LI.LLA-4 of Tine MeidieJ Schica &W SWOON CO"e Of MedCIC61. PWOIDMi. TX.

Johns Hooa~ins Lv;ratsttv iSatimore. Laryland and Waliter Intestinal igA tminaft9ruoo in sti*thuf&A& M~hw.m inecton Whl.~etherReed Atmo !nactiite of Research, WaahinSton. D.C. wuwu"posi gr fam rIims il," we onmoeiqoa

VR 6026 (VII). an 86-sinoquinoiine similar to pri.m IssahaneraviaAM twoflOani•. c'l1minnwwl fatoiwowirum a., . wilt

cuno. iav be & UeulS Luagent to tra fteumct 's~~j. citArin.L saymptrauns wiletoon. of even no disecte irdctin. Children In- tOE0pneumonia To find a dose that uouid provede desired WIR aniodag40ay caiworsaft in Houstonwa nelectf totfosmaiticin

plasma .evsis -ithouc ". nacceptabie toxicity. a riling andfrfgAaflyOdamtoaWdWv geone(10/59-4ig0)euieLpi•edos1. sanoomisteo doulfI-b•ind. pLacebo tP) "yIp-n3Ieemootddif Old5~5pC3'nAtlo (1aed4ih.concrolled SudY was coflducted. Sym•1lor owo" -a - "ya anspecornerim WWI Collt oa

V'- was give5n once daily at 5. 15, 30. i.1i or 60 mg/dav amasyt o oavnsb UA For 61 VdCiachedri~n. frlgA tgam wwefor 14. days to healChv men. Clinical laboratory costi and ea " wV w sa. For51

sympltoms vere monitored glood sampies were obtained for thaa o s cosig1 u urelac ahius MAltr odrug assav by MPLC to characterize pharmecokinecica. d5Winv~ in tw 5ipass b weeks e 64% a tW ed tlioftfi end

There -ere no significant differences between the 6R 1hotheiwonmsI had•a•eaxo tgrater asin 19Au W(p% 01).and P groups in the Lncidents or severity of laboratory 1inoing the neitdchieltdren. 611% Of thinytwspslmUCand n% of thiabncirmalies except for a slightly greator fail In the gaymptlatinaciilc tespod"(p-1)andr01AtMonsactimn" afterheoacocrit of W1i vs. P sub)ects (3.1% vs. 1.1%). 'imo tevossti (fps.42. AM chieh o hae• lhao baeno fyIncreasing dose nf UR caused reVersitls. saywpcoustic W 1:5 (ni2 benssdesd (Ve:410).MIMItwhonmIns10) ee

sethamogLobinaeia Mt) All subjects at 60 mg/day had M. snaympbe~. Ainwcinit*0lim with I"11g1Aambonoy. no it dstia nguishedwith peaso i of 18-6 9% inirsual 0-1.15%) occucring between thass~m on own nofm esrvbasa Itp21) otUKev aldhompratibmatfodays 8 end 17. thowe wonl asaymptodinana ' Mom (P-41). This Study Sidcauss fruat figA

The meon peak plasma concentration was 110 ng./ml C1t rmo04ueeam ago diwa ofad tirs abcon:syrpanals; and60 mg/dav (range 66-210 ng,/mi) The mezan terminal y"WM nslai nilf&OSArO6149 te:ccro whutolimisiation half-life ase Z9 hours. There was no evidenceof saturation kinecics These data Indicate chat s distetabb etmoev e atVa e• IhIW "MOf kvrolsf ieness; bsi preelwignl

be dosed once daily am, asna hetw vehis wilt ptmXn~ct Isisttcnone of iaees.

72* Vhj Eol4ogy of Acu Dimarrmi Hospitalize Young "1 Arel-amnommii Aavtive 04 Soluble Intasiremaia Adhesiontohdin. PENTLOPE H. DENY.HY.1 RDOIXL1' F- Uloimeie-t In Cal Cultres an Organ Cultures el Humnan

BEGCUE. SARA SPANGE.NB.RGER. BARBARA A. ReISpnfiy Elowhie'n. £ ARAUDA'. C CRUMP S MARLIN.V`JRUWE LS AND GEORGES PETER Bmw. Univrsity -an Rhode Island V MERLUZZI. arc F HAYDEN. UnfreeISy at Vrigina. Chennnesvisie. Vs andI4opm&L Pru~dsm P LI eSoeflsngst Irgeinin e htfrackul~dCal. Rld00* . Cit

Todcrtun te ooafenc viruse in Ins 04aeclg ofm acush diag o~ta e AM thatsitSlaio foc"OAAi ttecsito~q o hto-ro f dren o 2 ,n o Imvtaovsusea IRV). We hMe ""nod the In vitro e•storlznctrll earvicy of ade eopuil dwhv at 2 dar oif hagwli0wn ftd ail MO•m 001m s•olul formi of YC -I (stAM. in RIlpoCy. cyosti effea (CPE).ovshain 48 br; of admw ar at pas oftlaarrh. Slants were cind t iar nu r liISilfCCM oafi fea(P

• emW O MN ) by Wr I hModay4-d EL] Inmeotn amvs. 1 0-32 Winel sICAM-11 111211 RV CPE in wYf3 tfibroau

a od for o verin 7 doom EM m - c Dlah. -0 dsa AS 4 amo NIHeu cod n oisater infc•dla Vy 100 MOCO of 10 doeflrs rtnalt-groio

$coom or wasery suzls par day. drmuami - (0 days and no othe can" fot thel agdt0ypie of thinaviniml, N~o re N~usgi~tizlo of vid sintectve was found when" RV-39 (10' or 10' TCID wis M -i0e0 with 32 Unil aoCAM. I lo I hou1 aDsurig ftm two years of "0 ongoing may to dose X72(9%) a20425 pecomLs 331C. The 541000 alte arran of eiddeifi was suied" In Hain ceas ardecled at

adoudio he ren o w ludlw im 0.2 yis -ad urnmemad wae eninoded PAvmmof MOO of43 TCIO,/twe: vvwta* yi0 10 hourls was -10' TtlO~nv in Contemwif.vleis 1onetarmy Rates for am yaw Ip -ordsoedid "h -c5% Of plaza wish CAM-1 10 panWrdOO" am IeqeeVktSe replicatin whien added I haut berforsdiatomw wers no amueda. 192 (67%) plama had daintiee on &&wu Anld 90 or a me tlow of hcitaatolt. No0 signiica reducionso (-4i0" Were observed(33%) acquid dim durng hosplaitum. 19 (10%) with CJA ime hl olt w %n aI IS. 30. 60., 1*0 frsn. UOnotyer exposaure to SJCAU.l tot I

04itre ddrma c I.- 65 Mill Lad. mu Fsfold V = d(a 4hu phoo to woodiAasi 1,10 d by roffrovall dd has reamo tried. v~itlMilk•) o n o~mes vin 1 ufcor. wh1i EAd. momvin dconrains xmoI stgei the fact of arsida 8o1`14M The WWIy at SIKAM-I to w~itul RV-a9

far (107S). 3 (c I%) ma 2 (Ire%) cum rnspmesy. 3 dne m om 3 3 I5i of human 54t50. ThU was 04 In to *-Of 2mesh RY/EA4 and I me w~ai R~wVs'aaimsa d §ty/Amom"a 16 COBS. Ofistt fN'f WlUt WS1 a ecdI droda~paive with WA di me Nd hal ied s ad 24 (M%) had e.•ic exposed to 2000 rCIC6 IRV-3. Sucststif lets as 24. AS and 72 hours post-

7vu1 RV a to 20(13%) InhacomS• sd 1eruI (,ci%)ý 30111 eWe IIW0J(m found cofirle ofli oW yield wifthol , CM-lAy 10 of""dun fti mnl s wish RV/EA& No bogaie ew incsed is 99 (54%) CIA Sad 66 correa150 to 00trtaw (-10 TIIDU). SIC-AM- was r (iulty to Irte revicsuonC73%) INA cames. Reviw, at ,yocoaw *3=ý On dukdrus SOLW*3 wIn dsanm of thfW~r out, r"Wisovwee ft tin WI cot as and in hurman resisraorgp4M 0RV -GM UP~LCIl' sMOM Ugly W0 te dgrJWrWU thmn chi* an w th S*eielii. ilbsory ense was osets a" in the tosoiotwe cycle. but the

bceilor oveal agents tpeOOS). (ed 04 MyagjonI in vvmJ #V v boy dos incuatin with SICAMI.1. Sujggestsis 5ingy. vaelhogum Were loved a 35% o04 ocaIIo eb thtg the "PA41CAMI S55 a realiy rteverst.

T"65A at~' 04 chipp.40sa wedj YW?4pemif ~eSjys Aniiaocas Ant igentic sad Cenostic Analysis ofWO .14A.Respiratory Syncytolal Virus (RSV) Isolates

5tWmYAW .0 AbTINN.1.NE111119kMXt. 21MJ. frog a study of Nosocosial Infection. CAPWC)•NQ. Un~tv0yTesin~edaeli d dSeyltlO ef Storchc C5 gfell. ( Anderson. CS Park, 0 ODoneor.

SoTxmd 6 mnSy o Vhinglton Univ Scb M•d. St. Lulis. 11Oi Univ of RochesterO~ffmom.HOLMM rXSch moed. Rochester. Nil LZC. Atlanta. GA.

t*dsasgmhsdhe OWMV ssisMllogy mCF46M Ist le gi o c ODWOd oits . Wle so di,,t"d•Swolmn l.aWiins Raceft Recently developed techniques for antiganic and genomic

soma'7. i i Wlpmw ~ agaawt MOWN dinnazi analysis permit the recognition of differences amongI . mts i St�� � � strains of M that were previously thought to be

identical. VO have used monoclonal antibody (MCA) analysischwocW• d. l~r~and ribonucless protection (1t) to characterize isolatesinS IYWI4onid durr1 g OW ivln o (11W110440 wth W l SUM recovered during previoully reported studies of nosocosial

AIU0004U. 40chdrentad2luiturn - 0 drown. oepwindbfld RSV cacried out during the 1974-75 sld 1975-76 Seasons. ofiWW2ma•alu. I00oo, 1, I -(ances-d•u'wi u Shehy dding) 53 isolates recovered during those Itudies, 51 eret groupommt dit720"a W63%weIlsspsa t bullbOtdiemd t cauledby A San 2 vere group B. Alligenil Analysis of 43 group Aemlypt vins. Chldrennlot' If Il ourwow (noe1) 1IhdhIghre e•eown isolates using MCAs to the G glycoprotein classified 32 aso s.enrug J9A Vanlpe =,4l ient(pM and Soma" bbokVQ L ubgroup A/&. 9 am AX/, and I su AdT. Id' analysis of the G

(UMto type I V p hafO1)• hildsesn PA=oomm 010,1),d(ne ni). Ia glycoprotein geme of 36 group A Isolates revealed patternsed a i.Atlmlsts 0wlf lnm nO 1 lsimilar to, but distinct frai, the patterns of isolates

from the aid-late 19600. The Subgroup A/4 isolatesb•dcht (paxal. eBtosoes I of t:10esgsdesed in 10.21 included 2 distinct genoetc variants, vith minor genomicrnItt-hictad aItnmoI094aitypeIIls ch1 (P.-.01). M 1 1I*It-d variability present within each, as vell as among the All

SOmuWe l I MtO isolates. During both RSV seaons studied, strains from at

4121.•5•1 an2d 2/21( imm '<a11. least 2 subgroups vero isolated from patients and/or staffThesesatamnallhawsetg•unlAdhomierlyldoEBTome4ftwhlfOmadF n with nosocoeia.l itnfectiona. Clusters of particular strainsaouriananeradtuvve 5ietwad tW ila~p5Odum itpeaftMet could be traced. Ve conclude that some nosocosial

antfvyreemm areoy Samoa&" wtvwimesson. outbreaks of ISV consist of rialtiple distinct episodes oftransmission of different strains of ISV that arecirculating concurrently.

SI I I I t I I I I I I I 1 '1 1 I I

APPENDIX F

SUMHARY T.O. #10

JR 6026, an 8-aminoquinoline similar to primaquine, may be a useful

agent to treat visceral leishmaniasis and may hold an advantage over other

compounds used currently (e.g., pentavalent antimony, pencamidine, and

amphocericin B) in being more convenient and less toxic. A previous study

conducted at our institution determined that a single dose of 60 mg of WR 6026

administered as four 15 mg capsules was well tolerated with no adverse

symptoms and only minor elevations of serum aminotransferases, mild elevations

in lactic dehydrogenase, and a single case of minimally elevated serum

triglycerides. None of the subjects had an increase in methemoglobin. There

was a lag time of about 30 minutes between drug administration and detectable

plasma levels, a fourfold variation in areas under the plasma concentration-

time curve, and a half-life of 5.2-17.3 ho-4rs (mean 10.7 hours). In an effort

to find a dose that would provide desired WR 6026 levels in the blood over

long periods without unacceptable toxicity, a rising multiple-dose study was

conducted.

This study was a randomized, double-blind, placebo-controlled

investigation designed (1) to determine the pharmacokinetics of UR 6026 at

doses of 5 mg, 15 mg, 30 mg, 45 mg and 60 mg given once daily over 14

consecutive days in healthy men and (2) to assess the safety and tolerance of

these doses.

The clinical portion of the study was conducted between 16 Hay and 16

December 1988. Four subjects (two drug, two placebo) were studied at 5 mg, 30

mg and 45 mg per day; eight subjects (four drug, four placebo) were studied at

15 mg per day; and twelve subjects (six drug, six placebo) were studied at 60

(APPENDIX F p.2)

T.O. #10mg per day. The doses were generally well tolerated. One subject at 15 mg

per day developed elevated serum triglycerides after 7 days, and so the drug

was stopped. Thirty hours after the last dose was administered, this subject

appeared to have a grand maal seizure. In retrospect, the subject may have had

seizures on occasion before entering the study. No other subjects at this

dose or any of three higher doses had clinically significant adverse events

when compared to subjects receiving placebo in this study. The most frequent

symptomatic complaint was headache, present in four subjects receiving WR 6026

and three subjects receiving placebo. Serum transferase elevations during the

study were noted in five subjects receiving WR 6026 and seven subjects

receiving placebo. Some, usually minor, electrocardiographic changes

developed during the study in 10 subjects in each arm. The two groups did

differ in the mean fall in hematocrit observed during the study, 3.4% in

subjects receiving WR 6026 and 1.8% in subjects receiving placebo. This

difference was statistically significant but clinically insignificant.

Hethemoglobin elevations were noted in all six subjects receiving 60 mg per

day (peak methemoglobin 3.2 - 6.9%), and in one of two subjects who received

30 and 45 mg per day (1.8% and 3.4%, respectively).

The pharmacokinetic analysis of the serial blood concentrations indicate

that the drug accumulates over time. The mean peak and trough WR 6026

concentrations increased with increasing dose. Using a two-compartment

analysis, the mean beta elimination half-life was found to be 28.79 hours

(range 13.13 - 49.46 hours). Median areas under the WR 6026 concentration-

time curve were proportional to the dose of WR 6026, although there was two-

to threefold intersubject variation at each dose. Areas under the curve when

normalized to dose were similar at all doses, indicating that WR 6026

(APPENDIX F p.3)

T.O. #10

disposition obeys linear pharmacokinetics over the dosage range of 5 to 60 mg

daily,

Mechemoglobin concentrations increased with increasing IR 6026 doses.

Again, there were incersubject variations at each dose level. However, the

maximum increment in methemoglobin was highly correlated with the WR 6026 AUC.

No signs or symptoms resulting from methemoglobinemia were noted in any

subj ect.

We conclude that WR 6026 given in doses of up to 60 mg daily for 14

consecutive days is well tolerated. Further trials in subjects infected with

leishmania are indicated to assess the activity and efficacy of WR 6026.

APPENDIX GSUMMARY T.O0. # 1

Pyridostigmine bromide may be a useful agent to prevent death from

organophosphate exposure If given in advance of the exposure and if given In a

dose that is adequate to inhibit red blood cell acetylcholinescerase by 20-

40%. A previous study conducted at our institution determined that 16 mg of

pyridoscigmine bromide administered as syrup inhibited red blood cell

acecylcholinesterase by an average of 20% just over one hour after dosing, but

the average inhibition fell below 20% by about five hours after dosing.

Another study showed chat 22 mg of pyridoscigmine bromide in syrup gave an

average peak inhibition of 35% and provided at least 20% Inhib.tion for

slightly over 4 hours. A third study showed that 45 mg of pyridostigmine

bromide in syrup produced inhibition above 20% for at least 4 hours in all

eight subjects, with a mean duration of at least 20% inhibition of 5.99 hours.

The sustained-release tablets tested at equivalent pyridostigmine doses in

each of these studies were inferior in absorption and acetylcholinesterase

inhibition compared to the syrup. In an effort to find a formulation that

would provide adequate acecylcholinesterase inhibition for a longer period and

be more convenient for dosing than syrup, other sustained-release formulations

are being developed. The Osamee (an osmotic-delivery module) seemed promising

since in v it releases drugs (including pyridostigmine) into solution at a

constant, zero-order rate. If pyridostigmine were absorbed at a constant

fraction of the amount released, then constant pyridostigmine concentrations

and acetylcholinesterase inhibition could be achieved.

This study was designed (1) to compare the pyridostigmine bromide

pharmacokinetics in healthy men after single doses of 47 mg of pyridostigmine

bromide as syrup and after 141 mg of pyridostigmine bromide in an osmotic-

(APPENDIX G p. 2 )

T.O. #Il1

delivery module formulation (OsmeO), (2) to characterize the relative time

course of red blood cell acecylcholinesterase inhibition following the

administration of these tvo dosage forms of oral pyridostigmina bromide, and

(3) to assess the relative safety and tolerance of this suscained-release

formulation compared to pyridoscigmine bromide syrup.

The clinical portion of the study was conducted between 8 January and 3

February 1989. The plasma pyridostigmine levels and reduction in red blood

cell acetylcholinesterase activity were much lower after dosing with the

Osmece than with syrup. The mean peak plasma pyridostigmine level was 7.4

ng/ml with the Osmeca and 22.6 ng/ml with the syrup. The mean peak

ace/ylcholines terase inhibition was 19% with the Osmet5 and 40% with the

syrup. The relative bloavailability of the Osmee3 formulation compared to

syrup was 17.9%. After the syrup dosage, three of the eight subjects

developed gastrointestinal symptoms and another subject became lightheaded

with a reduction of diastolic blood pressure. Two subjects complaine, of

being sleepy 1-4 hours after the OsmecO dose, another developed nausea and

vomiting 39 hours after the Osmet 1 dose, and another developed soft stools

about 5 hours after the Osmeea dose.

APPENDIX H

SUMMARY T.O. #12

This study was designed (1) to compare the pyridostigmine bromide

pharmacokinetics in healthy men after single doses of 90 mg and 180 mg of

pyridostigmine bromide as Mestinon TimespanA tablets, (2) to characterize the

time course of red blood cell acecyleholLnesterase inhibition following the

administration of the two doses of oral sustained-release pyridostigmine

bromide, and (3) to assess the safety and tolerance of these two doses of

sustained- release pyridostigmine bromide.

The clinical portion of the study was conducted between 12 December and

23 December 1988, and showed that the two doses were well absorbed. One

subject became lightheaded at approximately the same time as his erythrocyte

acetylcholinesterase inhibition peaked at 58%. Another subject developed

gastrointestinal discomfort about an hour after each dose, but whether this

was due to mCssing breakfast rather than the drug is not clear, particularly

since the symptoms were more severe with the lover dose. The mean peak

inhibition for the four subjects receiving the 90 mg dose was 47% (range 39-

58%). and the inhibition was 20% or greater for a mean of 6.81 hours (range

4.25-11.50). The peak inhibition for the two subjects who received the 180 mg

dose was 62%. and the duration of inhibition of 20% or greater was 9.5-11.5

hours (mean 10.5).

APPENDIX I

SUMMARY T.O. #13

Niclosamide is a topical anti-schistosomal agent intended to prevent the

penetration of schistosomal cercariae through the skin. To be effective it

must be applied regularly in anticipation of exposure. Because of its

structural similarity to known topical photoallergens, it may induce contact

sensitization and/or contact photoallergy upon repeated application. To

assess these possibilities, we conducted this study in a total of 45 healthy

white subjects. Caucasian subjects were used to enhance our capacity to

observe irritancy and allergic responses compared to more pigmented races

(blacks or Orientals).

This study was conducted in two parts. The first part was designed to

determine the irritancy threshold of niclosamide in petrolatum and of sodium

lauryl sulfate (SLS). This portion of the study was conducted in 20 subjects

as a randomized, double-blind, placebo-controlled investigation. The second

portion of the study was designed to determine the contact sensitization and

contact photoallergic potential of niclosamide and was conducted in 25

subjects. The contact sensitization portion was performed as an open study

and was carried out in two parts -- an induction phase and a challenge phase.

The first portion of the study showed that the irritancy threshold for

niclosamide in petrolatum was 75% (weight/weight). However, because this

concentration was so dry and flaky, and therefore would not remain apposed to

the skin in the contact sensitization phase, the next lowest concentration

(50%) was used. The second portion of the study showed no evidence of contact

sensitization or contact photoallergy in any of the 25 subjects upon

rechallenge t•wo weeks after completing the sensitization phase.

m i i i i in mi i i i

(APPENDIX I p. 2) TO 1

These results indicate a low likelihood of contact sensitization or

contact photoallergy in response to topical niclosamide. We believe that with

the benefit of these data, multiple-dose studies of both safety and efficacy

can now be conducted.1

1

APPENDIX J

SUMMARY T.O. #14

Pyridostigmine bromide may be a useful adjunct to atropine to prevent

death from organophosphate exposure if given in advance of the exposure and if

given in a dose that is adequate to inhibit red blood cell acetylcholin-

esterase by 20-40%. Previous studies conducted at our institution determined

that single doses of pyridostigmine bromide administered as syrup inhibited

red blood cell acetylcholinesterase by 20-40% for a longer period of time than

equivalent doses of various "sustained-release" tablets and capsules; but

syrup is inconvenient in a field situation. The best experimental sustained-

released formulation (45 mg capsule) kept red blood cell acetylcholinesterase

inhibition above 20% for four hours. In an effort to find a formulation that

would provide adequate acetylcholinesteraea inhibition for a longer period,

other formulations are being investigated.

This study was designed (1) to characterize the pyridostigmine bromide

pharmacokinetics in healthy men after single doses of two oral dosage forms of

pyridostigmine bromide, one a sustained-release preparation and the other a

standard tablet, and compare these to the pharmacokinetics of a prolonged

intravenous pyridostigmine infusion, (2) to characterize the time course of

red blood cell acetylcholines terase inhibition following the administration of

these two oral dosage forms and compare these to the inhibition occurring with

intravenous pyridostigmine. (3) to assess the effect of food on the

pharmacokinetics and pharmacodynamics of the two oral pyridostigmine dosage

forms, and (4) to assess the safety, tolerance, pharmacokinetcics, and

pharmacodynamics of multiple doses of the oral formulations over two days.

(APPENDIX J p.2)T.O. #14

The clinical portion of the study was conducted between 11 March and 26

May 1990, and showed that the mean bioavailability of the sustained-release

tablet given fasting was 8% by pharmacokinetic assessment and 8% by assessment

of the inhibition of erythrocyte acecylcholinesterase when compared to

intravenous pyridostigmine. The bioavailabiliry of the standard tablet given

fasting was 17% by pharmacokinetic assessment and 19% by assessment of

acetylcholinesterase inhibition. The effect of food on the inhibition of

erythrocyte scetylcholinesterase activity was minimal for the sustained-

release formulation, shifting the acetylcholinesterase inhibition-time curve

about two hours to the right. On the other hand, food caused a reduction in

the degree of acetylcholinesterase inhibition following the first standard

tablet with food, but this effect was absent when the inhibition-time curve at

steady stare with feeding was compared to the fasting dose. Both formulations

were well tolerated when given in multiple doses over two days.